Preparing For Work Intake Form 2024 Online registration form Step 1 of 6 16% This class is sponsored (paid by) by the City of Bellevue. The City of Bellevue would like us to gather more information about our students. All information is kept private and confidential. Please answer the following questions: Class Choice*Preparing For Work (Tuesday evenings)On the Job Communications (Thursday evenings)I can take either class (Tuesday or Thursday evenings)Name*Please use your legal name. We are not able to register students who use alternative or preferred names. First Last Have you applied to Bellevue College before?*This is a different application than this form and the ESL Intake form. YesNoI don'tBellevue College ctcLink ID#* Did you take one of these classes before?*Preparing for WorkOn the Job CommunicationsI have not taken these yetPhone Number* Personal Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Birth Date* Month Day Year Age*18-2425-3435-5455-7474-84Sex*MaleFemaleTransgenderPrefer Not to AnswerWhat is your race?* African/African American/Black (872) Alaska Native (015) American Indian (597) Asian Indian (600) Chinese (605) Filipino (608) Hispanic or Latino (717) Japanese (611) Korean (612) Native Hawaiian (653) Thai (618) Vietnamese (619) White (800) Other Asian (621) Other Pacific Islander (681) Other Race (799) Prefer not to disclose (999) Are you studying/have you studied in a U.S. college level program, certificate or degree?* Yes No Please tell us where you attend and what did you study (or are you studying). Are you an English as a Second Language speaker?* Yes No Please tell us about your ESL Level* I am not an ESL student ESL Level 6 ESL Level 5 ESL Level 4 ESL Level 3 or lower I Don’t Know Are you an immigrant or refugee, or a new arrival to this country?* Yes No Are you a tourist or international student?*Do you hold a J-1, F-1, M-1, B-1 or B-2 VISA? Yes No Will you be living in Washington State during the current quarter?* Yes No Are you homeless (you do not have a place to live)?* Yes No Do you consider yourself to be a person with a disability (a problem with health)?* Yes No Including yourself, how many individuals live in your household?*The number of people living in your house that share an income. 1 2 3 4 5 6 7 8 What is your annual household or family income?*How much does the family earn together in one year? under $27,200 $27,200 to $45,299 $45,300 to $66,749 above $66,750 What is your annual household or family income?*How much does the family earn together in one year? under $31,050 $21,050 to $51,799 $51,800 to $76,249 above $76,250 What is your annual household or family income?*How much does the family earn together in one year? under $34,950 $34,950 to $58,249 $58,250 to $85,799 above $85,800 What is your annual household or family income?*How much does the family earn together in one year? under $38,800 $38,799 to $64,699 $64,700 to $95,299 above $95,300 What is your annual household or family income?*How much does the family earn together in one year? under $41,950 $41,950 to $69,899 $69,900 to $102,949 above $102,950 What is your annual household or family income?*How much does the family earn together in one year? under $45,050 $45,050 to $75,099 $75,100 to $110,449 above $110,550 What is your annual household or family income?*How much does the family earn together in one year? under $48,150 $48,150 to $80,249 $80,250 to $118,199 above $118,200 What is your annual household or family income?*How much does the family earn together in one year? under $51,250 $51,250 to $85,449 $85,450 to $125,800 above $125,800 Are you willing to work online 4 hours each week?* Yes No Are you comfortable using a computer?* Yes No Do you have a computer or laptop?* Yes No Do you have access to internet?* Yes No THANK YOU FOR ANSWERING THE QUESTIONS. * We will confirm your place in class if you meet the program requirements. * We will tell you if we cannot register you for this class. * Bellevue residents are given priority. We will serve non-Bellevue residents if space is available. Photo Release*I, the undersigned, consent to each and every use by Bellevue College, and all of its officers, employees, and agents of 1) each photograph, videotape or other likeness of me taken/recorded on (date) and/or 2) comments provided in interviews on (date) and/or in writing. Such uses may include, but are not limited to, every use in a publication, newspaper, advertisement, web site, videotape presentation, television show or other publication or recording. I also waive any right to compensation for such uses, or to inspect or approve the uses beforehand. I release Bellevue College, its legal representatives and all persons acting under its permission or authority, from any liability for any blurring, distortion, alteration or optical illusion that may occur with these pictures. I, the undersigned, consent to each and every use by Bellevue College, and all of its officers, employees, and agents of 1) each photograph, videotape or other likeness of me taken/recorded on (date) and/or 2) comments provided in interviews on (date) and/or in writing. Such uses may include, but are not limited to, every use in a publication, newspaper, advertisement, web site, videotape presentation, television show or other publication or recording. I also waive any right to compensation for such uses, or to inspect or approve the uses beforehand. I release Bellevue College, its legal representatives and all persons acting under its permission or authority, from any liability for any blurring, distortion, alteration or optical illusion that may occur with these pictures. I Agree I Decline e-signature*I agree to be bound by the terms of this Electronic Consent Agreement with the Photo Release Policy I also consent to the use of electronic signatures in place of written documents and handwritten signatures and to electronic communications. Date of Consent:* Bellevue College does not discriminate on the basis of race, color, national origin, language, sex, sexual orientation, including gender identity or expression, disability, or age in its programs and activities. Please see policy 4150 at www.bellevuecollege.edu/policies/. The following people have been designated to handle inquiries regarding nondiscrimination policies: Title IX Coordinator, 425-564-2641, Office C227, and EEOC/504 Compliance Officer, 425-564-2178, Office R130. Month Day Year Last Updated October 30, 2023